There were more than 1,300 open investigations into patient abuse, neglect or fraud at skilled nursing facilities at the end of 2022, the Health and Human Services Office of Inspector General revealed in mid-March.

That was, far and away, the most among inpatient and residential providers.

Providers should expect more enforcement activity in 2023 from Medicaid Fraud Control Units as various state and federal enforcement entities continue to ramp back up after COVID.

“Agencies typically prioritize situations where resident harm has occurred or there are clear risks to the heath, safety and well-being of facility residents. I have no doubt that similar kinds of concerns will drive enforcement going forward,” warned Jesse Berg, a partner with Lathrop GPM’s Minneapolis office.

Q: Your JAMA Health Forum study compared delivery of physical therapy, occupational therapy and speech language therapy to nursing home residents before and after the pandemic started. What did you learn?

A:Our goal was to characterize changes in rehabilitation services provided by SNFs during COVID-19. Rehabilitation services overall decreased, but only by about a half day on average.

Q: What does that tell us about nursing homes’ resourcefulness?

A:So much has been made about the shortcomings of nursing homes during the pandemic, and while there are a lot of opportunities for [facilities] to improve, this shows they are getting some things right. We were surprised to see that despite the challenges and regulations, it was possible to do the group sessions and there wasn’t a drop-off in the intensity. It speaks to the strength and resilience of staff during that time.

Q:Were you surprised to see an average fall-off of only about 10%, given COVID-related restrictions?

A:We went into this concerned that nursing home residents might not have been getting as much therapy and rehabilitation due to pandemic challenges. I would hope [this research] gives people confidence that for patients who still need nursing-home level care, it’s still an OK option.

A: Congratulations on your new position! I would look up the Centers for Disease Control and Prevention tools in Project Firstline. It is laid out to assist you as the IP, and to allow you to pull interactive video and print training materials for your staff.

There also are YouTube videos explaining  elements of the Firstline program. It strives to ensure everyone realizes that Infection prevention is an “essential” part of caring for and protecting patients. 

“When you can understand and apply infection control actions consistently and confidently — every person, every action, every day — it saves lives,” organizers said.“CDC’s Project Firstline provides innovative and accessible resources so all healthcare workers can learn about infection control in healthcare [and] about where germs live in healthcare settings and how to recognize the risk for them to spread — which is the first step in understanding when to take action to protect your patients and yourself from infections.”

As a healthcare provider, you’ll learn to recognize infection risks — and take action “to protect your patients and yourself, no matter the situation.”

Taking this course gives you confidence in knowing you are providing the best possible and safest care for your residents.

If you love IP and want to be further credentialed, there are other courses and certification exams available through NADONA, CDC and APIC. Which you choose just depends on the amount you want to spend obtaining the certification, and whether you prefer taking self-paced online classes or learning in person.

Post-acute care needs more supportive, well-trained staff, so thanks for being so diligent.

Please send your resident care-related questions to Sherrie Dornberger at ltcnews@mcknights.com.

Their trial included 372 hospitalized adults 50 and older taking five or more medications who were scheduled to transition to post-acute care. Participants followed a protocol called Shed-MEDS developed at Vanderbilt University Medical Center. A pharmacist or nurse practitioner provided a comprehensive medication review and patient- or proxy-approved deprescribing recommendations. Deprescribing was initiated in the hospital and continued throughout a post-acute facility stay. A control cohort received usual care in both settings. 

Patients who received the intervention had an average of 14% fewer medications at post-acute facility discharge and 15% fewer medications at a 90-day follow-up compared with the control group. 

The Shed-MEDS protocol also was linked to a decrease in potentially inappropriate medications and fewer sedative and anticholinergic drugs, investigators reported. There was no evidence of adverse events.

A: In post-acute and long-term care facilities,  older adults with lower extremity  wounds may have unknown ulcer etiology. Is it arterial, venous or both? Does it have associated neuropathy? Diabetics with arterial vascular disease may not manifest pain.

In some facilities, staff opt for the in-house audible handheld Doppler ultrasound (AHHD), which can provide bedside testing. Information from an AHHD can benefit the patient, but it does not supersede the importance of history taking and examination. 

Arterial ulcers are often painful unless patients have severe neuropathies. Such patients suffer with claudication pain. It may be a stabbing, burning sharp and/or achy pain associated with ambulation. It is relieved with rest. With disease progression,  pain becomes persistent and gnawing. It often causes severe sleep disturbances. For a patient with any wounds, it is also helpful to explore whether the ulcer is healable. 

Noninvasive bedside testing is ideal for older patients in post-acute or long-term care settings. It can allow the wound care expert to rule out peripheral arterial disease. However, it may be falsely high in diabetics (80%) and older adults (20%). A Doppler with 8-MHz or more yields the best results. Just placing the Doppler on the lower extremity vascular system is not enough. Also perform a procedure to check for the ankle-brachial pressure index (ABPI)..

As of today, the arteriogram remains the gold standard for arterial testing and is done when a bypass or arterial dilation procedure is required. 

It may not be a big deal whether or not you have AHHD in your facility, but what is more important is how the healthcare team provides person-centered care. It is best to strive for healthy habits and healing, regardless of the patient.

That’s according to a study of nearly 1,800 Belgian wound clinic patients, but the findings have implications for all who care for patients with diabetes. Researchers suggest attention to sex should be used to optimize preventive and therapeutic strategies.

Researchers pointed to a worse vascular state associated with men’s higher rate of previous or current smoking as one potential contributor. Men in the study also more frequently presented with more severe symptoms of peripheral artery disease, including critical limb ischemia.

Overall, ulcers in men were deeper, more frequently open to the bone, and more frequently “deeply infected.” Twice as many men presented with systemic infection as women. Men demonstrated a higher prevalence of previous lower limb revascularization, while women presented more frequently with renal insufficiency. The full study was published in PLOS One in February. n

A: Facility-wide assessments determine the resources necessary to care for residents competently. Yet information from the facility assessment also can help improve resident care and outcomes. 

For this question, let’s focus on one required item: resident-level information, such as diseases, conditions, physical and cognitive disabilities, and overall acuity. This one item can inform multiple decisions regarding facility resources.

Budget-use — Facility assessments might prompt adjustments for resources such as the number and type of staff, equipment and staff education costs. For example, if the assessment shows a high volume of wounds, a facility might invest in a certified wound nurse, who could educate on wound care and treatments. 

Education — Apply resident diagnosis information to competency-based educational offerings for all staff. For example, if 60% of residents have a diagnosis of depression, provide staff education on depression. Similarly, review facility-acquired infections and have the infection preventionist develop education on preventing these types of infections.

QAPI — Compare the facility assessment to that of previous years. Look for trends that may merit a performance improvement plan. Decreasing infections, wounds, falls, weight loss and behaviors all improve resident outcomes. 

Annually reviewing the facility assessment can yield information that helps facility leaders tailor care delivery. Using that information as a planning tool to assist with budgeting, education and QAPI efforts provides an opportunity to care not only competently, but in a way that also improves resident outcomes.

Please send your nursing-related questions to Amy Stewart at ltcnews@mcknights.com. 

The study included 57 long-term care facilities, determined the relationship between intrapersonal, interpersonal, and environmental factors and mealtime difficulties. It also sought to identify which factors were most influential.

Key intrapersonal factors included age, cognition, activities of daily living and the number of beds in the facility. Influential environmental factors included the education and training of mealtime assistants, and whether an environment suitable for eating had been established. Researchers found the best environments provided adequate food and utensils reflecting individual preference or eating abilities, gave residents enough time to eat and ensured mealtimes were taken together with other residents. 

“Furthermore, it is essential that different levels of adequate nursing staff be set according to facility size,” researchers wrote in the Journal of Nursing Management. They also called on managers to strategically position direct care staff at meal times. 

The project’s goal was to centralize all of the organization’s data into a functional data warehouse. UMC came into the project with limited experience with robotic process automation and only a basic understanding of the organization’s critical business processes, according to the study. Many functions were still being performed manually and data was siloed. 

The study showed that integrating robotic process automation translated to a 75% reduction in processing time and an estimated savings of more than $250,000 in recaptured labor productivity. 

“Eliminating the need for employees to manually look up information also improves overall efficiency and processing time. Additionally, the low-code Microsoft PowerApps allows for easy customization and scalability and ensures we can adapt it to the changing needs of the organization,” CAST said.

One of the project’s biggest challenges was figuring out how to transfer more than 80,000 resident documents and attachments, including lab results, entrance agreements and power of attorney forms, without risking the integrity of resident data. UMC, along with the Robotic Process Automation Center of Excellence, created an RPA bot in 14 days to automate the process of categorizing and uploading documents to the new system. 

“The deployment of the bot was a success, and within a week all the documents were transferred to the new system, saving a significant amount of time and Labor,” according to CAST. “The RPA bot was highly efficient and helped to maintain the integrity of resident data during the [electronic medical records] migration process.”

A: Not exactly, but the Centers for Medicare & Medicaid Services may be taking a sooner-rather-than-later approach.

While not yet finalized, CMS issued a proposed rule in December 2022 that would, in part, amend existing regulations for Medicare Parts A, B, C and D regarding the standard for an “identified overpayment” and remove the “reasonable diligence” standard. As it stands, providers have a reasonable diligence period to investigate and quantify any Medicare overpayments that might have been received within a 6-year lookback period. Without this, providers may have much less time to quantify and refund a Medicare overpayment. 

How much time, exactly? That remains to be seen. Existing law requires providers to report and return the overpayment by the later of: (1) the date which is 60 days after the date on which overpayment was identified; or (2) the date any corresponding cost report is due, if applicable.

CMS proposes to replace “reasonable diligence” with language that gives the terms “knowing” and “knowingly” the same meaning given those terms in the False Claims Act if a supplier has identified an overpayment if it has actual knowledge of the existence of the overpayment or acts in reckless disregard or deliberate ignorance of the overpayment. Obviously, it will be challenging to determine or “identify” the extent of potential overpayments within the 60-day period and without clarification on what “identified” means in this regard. 

Your compliance program and self-monitoring efforts will be as important as ever to avoid overpayment scenarios before they happen. CMS does not have a basis for estimating the impact associated with this amendment. When finalized, provisions will take effect beginning Jan. 1, 2024.

Please send your payment-related questions to Eleisha Wilkes at ltcnews@mcknights.com.